MARC U*STAR Honors Program and PRIDE Summer Diabetes Program

Pre-Qualifying Application Form

Updated: 03/14/2008

 

  
   
For Which Program(s) Are You Applying?

PRIDE Program: MARC U*STAR Program:
NAME:


(Last,  First  Middle)

SEX:

Resident Status:
DATE OF BIRTH:

- -
(Month - Day - Year)

CITIZENSHIP:
U.S.       Other
  Type of Visa
BIRTHPLACE:

EMAIL ADDRESS:

CURRENT ADDRESS:

PERMANENT MAILING ADDRESS:

CURRENT TELEPHONE:

PERMANENT TELEPHONE:

PAGER:

CELL PHONE:

Ethnic Origin (Check all that apply): If selecting more than one group, please press the control button and click on appropriate selections.
Other Ethnic Group:

ACADEMIC INFORMATION

CLASS STANDING:
 		MAJOR:
EXPECTED DEGREE:
 		EXPECTED DATE OF GRADUATION:
SCIENCE COURSES GRADE POINT AVERAGE:
(max. 4.0)
CUMULATIVE GRADE POINT AVERAGE:
(max. 4.0)

SCHOOL AND WORK EXPERIENCE

Please list the name and type of institutions (college, university, trade school, business school, high school, etc.) that you have attended. Start with the most recent one you attended (or are attending) and work backward.

 
Years
From - To 		Institution Name Location Type of Institution Degree, Diploma or Certification
Please list the work and military experience. Starting with the most recent (or present) job and work backward.
Month/Year
From - To 		Employer or Branch of Service Job Description or Rank, if Military

 

Are you now receiving financial assistance in order to attend the University of Hawaii?
Yes No

If yes, what type:

 

If submission fails, please fax your answers to 956-2892.

Mahalo!